AMWU Wins NSW Workers Compensation Changes

The Australian Manufacturing Workers Union has won significant changes to the NSW Workers Compensation Guidelines that will make it easier for injured workers to access the treatment they need.

The changes concern the ability to access treatment without pre-approval from an employers' insurance company. The relevant guideline changes are listed below:

Accessing treatment without pre-approval Workers can receive the following reasonably necessary treatments and services as a result of the work related injury (including reasonably necessary travel) without pre-approval from the insurer.

Treatment

Expense

Initial treatment

Any treatment within 48 hours of the injury happening.

Nominated treating doctor

Any consultation or case conferencing for the injury, apart from telehealth and home visits.

Any treatment during consultation for the injury, within one month of the date of injury.

Public hospital

Any services provided in the emergency department, for the injury.

Any services after receiving treatment at the emergency department for the injury, within one month of the date of injury.

Medical specialists

If referred by the nominated treating doctor, any consultation and treatment during consultations for the injury (apart from telehealth), within three months of the date of injury.

Note: Medical specialist means a medical practitioner recognised as a specialist in accordance with the Schedule 4 of Part 1 of the Health Insurance Regulations 1975 who is remunerated at specialist rates under Medicare.

Diagnostic investigations

If referred by the nominated treating doctor for the injury:

▪ any plain x-rays, within two weeks of the date of injury

▪ ultrasounds, CT scans or MRIs within three months of the date of injury, where the worker has been referred to a medical specialist for further injury management. On referral by the medical specialist for the injury, any diagnostic investigations within three months of the date of injury. Note: A General Practitioner’s MRI referral must meet the Medicare Benefits Schedule criteria.

Pharmacy

Prescription and over-the-counter pharmacy items prescribed by the nominated treating doctor or medical specialist for the injury and dispensed:

▪ within one month of the date of injury, or

▪ after one month of the date of injury if prescribed through the Pharmaceutical Benefits Scheme.

Up to eight consultations if the injury was not previously treated and treatment starts within three months of the date of injury.

Up to three consultations if the injury was not previously treated and treatment starts over three months after the date of injury.

Up to eight consultations per Allied health recovery request (AHRR) if the same practitioner is continuing treatment within three months of the date of injury and:

▪ the practitioner sent an AHRR to the insurer, and

▪ the insurer did not respond within five working days of receiving the AHRR. One consultation with the same practitioner if the practitioner previously treated the injury over three months ago. This is a new episode of care. One consultation with a different practitioner if the injury was previously treated. Up to two hours per practitioner for case conferencing that complies with the applicable Fees Order. Up to $100 per claim for reasonable incidental expenses for items the worker uses independently (such as strapping tape, theraband, exercise putty, disposable electrodes and walking sticks). Notes:

▪ Consultations with an accredited exercise physiologist require a referral from a medical practitioner.

▪ All treatments exclude home visits, telehealth and practitioner travel.

▪ A list of SIRA approved practitioners can be found at www.sira.nsw.gov.au. See the SIRA workers compensation guideline for the approval of treating health practitioners for more on practitioner approval.

SIRA-approved psychologist or counsellor

Up to eight consultations if a psychologist or counsellor has not previously treated the injury and treatment starts within three months of the date of injury.

Up to three consultations if a psychologist or counsellor has not previously treated the injury and treatment starts over three months after the date of injury.

Up to eight consultations per Allied health recovery request (AHRR) if the same practitioner is continuing treatment within three months of the date of injury and:

▪ the practitioner sent an AHRR to the insurer, and

▪ the insurer did not respond within five working days of receiving the AHRR. One consultation with the same psychologist or counsellor if the practitioner previously treated the injury over three months ago. This is a new episode of care. One consultation with a different psychologist or counsellor if the injury was previously treated. Up to two hours per practitioner for case conferencing that complies with the applicable Fees Order. Up to $100 per claim for reasonable incidental expenses for items the worker uses independently (such as relaxation CDs and self-help books). Notes:

▪ These consultations require a referral from a medical practitioner.

▪ All treatments exclude home visits, telehealth and practitioner travel.

▪ A list of SIRA approved practitioners can be found at www.sira.nsw.gov.au. See the SIRA workers compensation guideline for the approval of treating health practitioners for more on practitioner approval.

34 Guidelines for claiming workers compensation

Treatment

Expense

Interim Payment Direction

Any treatment or service under an Interim Payment Direction from the Registrar (or delegate) of the Workers Compensation Commission directing that medical expenses be paid.

Section 297 of the 1998 Act

Commission determination

Any treatment or service that has been disputed and the Workers Compensation Commission has made a determination to pay for treatment or services.

Permanent impairment medical certificate

Obtaining a permanent impairment medical certificate or report, and any associated examination, taken to be a medical-related treatment under section 73(1) of the 1987 Act.

Section 73 of the 1987 Act

Hearing needs assessment

The initial hearing needs assessment where the:

▪ hearing service provider is approved by SIRA, and

▪ nominated treating doctor has referred the worker to a medical specialist who is an ear, nose and throat doctor, to assess if the hearing loss is work-related and the percentage of binaural hearing loss. Note: Hearing needs assessment includes obtaining a clinical history, hearing assessment as per Australian/New Zealand Standard 1269.4:2005, determination of communication goals, recommendation of hearing aid and clinical rationale for hearing aid.

How to claim treatment and services

As a worker, you or your provider must give the insurer enough information to determine whether the treatment or service you have asked for is or was reasonably necessary.

▪ specialist referrals or reports. If the insurer needs to know more, it should first contact the treatment provider. If the provider does not supply more information, or the information is inadequate or inconsistent, the insurer may then ask for an independent opinion. This may require you to attend a medical appointment. WorkCover guidelines on independent medical examinations and reports

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